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Case 3

Diagnosis

adenocarcinoma in situ

 

Progress

Biopsies were taken at 1 and 8 o’clock and four quadrants. Cervical biopsies at 1 and 3 o’clock came back to be CIN III. Other biopsy results and the endocervical curettage were negative. Large loop excision of transformation zone (LLETZ) was performed under local anaesthesia. Pathology revealed adenocarcinoma in situ (ACIS) at 3-6 o’clock with clear margin.

 

As patient is contemplating pregnancy, she was advised to have regular cervical smear with endocervical brush. She was counseled on hysterectomy after completion of family as ACIS is difficult to be monitored.

 

Discussion

Cervical cancer screening is mainly based on cervical cytology in Hong Kong, which has its inherent limitations such as false negative rates in up to 20% for detecting invasive carcinoma1.

 

Persistent high risk HPV infection strongly predicts the risk of CIN II or III and invasive cervical cancer in later life. Its role as a necessary factor in the development of malignancy has been ascertained through previous works2. Different groups around the world have been looking into its role in primary screening. High risk HPV testing has high negative predictive value and higher sensitivity especially in detecting high grade lesions when compared to cytology. However, on its own, the specificity is quite low if used for population-based screening, potentially leading to great increase in amount of referrals for colposcopy3. Currently high risk HPV testing is incorporated into the screening strategy in Hong Kong to triage patients with ASCUS for colposcopy.

 

In this case, if HPV testing and colposcopy were not done, the high grade lesion would be left unnoticed until the patient comes back for her second smear. In fact, women with negative cytology but positive HPV testing run a higher risk of CIN III than those who are HPV negative4. The latest ASCCP guidelines updated in 2012 recommends that for women with negative cytology but a positive HPV test to either repeat co-testing (cytology and HPV testing) in 1 year or perform HPV DNA typing. Colposcopy would be required in those whose smear shows ASCUS or worse on repeat or those harbouring HPV 16/ 185.

Co-testing is now the preferred screening strategy for women from 30-64 years according to the latest ASCCP guidelines. It allows spacing out of the screening interval to 5 years in women above 30 years old (compared to every 3 years for cytology alone). This screening strategy maximizes early detection of CIN III or more and yet not excessively increasing the number of colposcopies and should be considered in Hong Kong as well 6.

 

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